Coagulation and fibrinolysis dr shabeel pn

Hemostasis Blood must be fluid Must coagulate (clot) at appropriate time Rapid Localized Reversible Thrombosis…inappropriate coagulation

3 Major systems involved Vessel wall Endothelium ECM = BM (type 4 collagen + other proteins) Platelets Coagulation cascade Coagulation factors (proteins) Names and numbers Active and inactive forms (zymogens)

Thrombogenic Antithrombogenic Vessel injury (Favors fluid blood) (Favors clotting)

Antithrombotic Properties of the Endothelium Anti-platelet properties Covers highly thrombogenic basement membrane Uninjured endothelium does not bind platelets PGI2 (prostacyclin) and NO from uninjured endothelium inhibit platelet binding ADPase counters the platelet aggregating effects of ADP

Antithrombotic Properties of the Endothelium Anticoagulant properties Antithrombotic Properties of the Endothelium Anticoagulant properties *HEPARIN-LIKE MOLECULES: activate anti-thrombin III (inactivates active proteases) *THROMBOMODULIN: changes specificity of thrombin (activates protein C , which inactivates factors Va and VIIIa *Endothelial cells produce tPA which activates fibrinolysis via plasminogen to plasmin

Prothrombotic Properties of the Endothelium Synthesis of von Willebrand factor Release of tissue factor Production of plasminogen activator inhibitors (PAI) Membrane phospholipids bind and facilitate activation of clotting factors via Ca bridges

Intrinsic pathway XIIa Extrinsic Pathway XIa TF Prothrombin IXa VIIa VIII VIIIa Xa Va V Soft clot Thrombin Fibrinogen Fibrin XIIIa Hard clot Fibrin

Coagulation Cascade Enzymatic cascade (amplification) Several serine proteases Produced by liver (most) Require Vit K (several) 3 protein cofactors (not enzymes) Requires Ca 2+ Localized to site of injury Reversible (via production of plasmin)

Fibrinogen Fibrin

Thrombin Fibrinogen Fibrin

Prothrombin Xa Va Thrombin Fibrinogen Fibrin

Extrinsic Pathway TF Prothrombin VIIa Xa Va Thrombin Fibrinogen Fibrin

Intrinsic pathway XIIa Extrinsic Pathway XIa TF Prothrombin IXa VIIa VIIIa Xa Va Thrombin Fibrinogen Fibrin

Intrinsic pathway XIIa Extrinsic Pathway XIa TF Prothrombin IXa VIIa VIIIa Xa Va Soft clot Thrombin Fibrinogen Fibrin XIIIa Hard clot Fibrin

Intrinsic pathway XIIa Extrinsic Pathway XIa TF Prothrombin IXa VIIa VIII VIIIa Xa Va V Soft clot Thrombin Fibrinogen Fibrin XIIIa Hard clot Fibrin

Hemophilia A Deficiency of/nonfunctional VIII Hemophilia B Deficiency of /nonfunctional IX Why do they bleed?

Intrinsic pathway XIIa Extrinsic Pathway XIa TF Prothrombin IXa VIIa VIII VIIIa Xa Va V Soft clot Thrombin Fibrinogen Fibrin XIIIa Hard clot Fibrin

Revised Coagulation Pathway (Tissue Factor Pathway) IX TF Prothrombin (II) IXa VIIa Xa Thrombin (IIa) NB: production of IXa Interaction of intrinsic and extrinsic pathways

Tissue Factor Pathway Inhibitor Kunitz-type protease inhibitor (kringles) 34 and 41 kD forms in plasma (C-term truncation) Directly inhibits Xa Inhibits VIIa-TF complex in a [Xa]-dependent manner Bound to LDL, HDL and Lp (a) ~10% present in platelets (endothelium also)

Tissue Factor Pathway Inhibitor IX TF Prothrombin (II) IXa VIIa Xa TFPI TFI Thrombin (IIa) NB: Inhibition of Xa and VIIa

Net result: Tissue Factor Pathway Production of IXa Production of small amounts of thrombin (IIa) NB: no/little fibrin formed!

V VIII Thrombin (IIa) Va VIIIa

Tissue Factor Pathway NB: activation of IX by VIIa IX TF Prothrombin IXa VIIa VIII VIIIa Xa Va V Soft clot Thrombin Fibrinogen Fibrin XIIIa Hard clot Fibrin

Tissue Factor Pathway VIIa forms as usual via binding of VII to TF VIIa activates some XXa Xa converts a small amt of prothrombin to thrombin; this thrombin is used to produce small amts of VIIIa and Va As the conc of TF-VIIa-Xa-thrombin increases, Tissue Factor Pathway Inhibitor inactivates this complex stopping further production of thrombin. New: VIIa also activates IXIXa (Key to new scheme) IXa, with VIIIa (produced as above), produces Xa; this Xa with Va (produced as above) produces new thrombin; this thrombin produces more VIIIa and Va and now we get lots of thrombin and fibrin!

Physiologic Inhibitors of coagulation Antithrombin III (serpin) Activated Protein C + protein S Inactivates Va and VIIIa (via proteolysis) NB: Factor V Leiden Thrombomodulin (EC glycoprotein) Binds to thrombin Decreases ability to produce fibrin Increases ability to activate Protein C

Role of vitamin K

Role of vitamin K Some clotting factors require a post-translational modification before they are active in clotting These factors are II, VII, IX, X, proteins C and S This PTM involves the addition of a COO- to certain Glu residues in the clotting factors This PTM results in the formation of several g-carboxy glutamates = Gla This PTM requires vitamin K

Role of vitamin K Vit K is altered in carboxylation Rx and must be regenerated before reuse Regeneration involves 2 reductases which convert vit K epoxide to vit K Vit K antagonists inhibit these reductases Vit K-dependent PTM provides sites on modified coag factors for Ca bridgeing

Non-physiologic inhibitors of coagulation Vitamin K antagonists (in vivo only) Ca chelators (in vitro only) EDTA Citrate Oxalate * Heparin (in vivo and in vitro)

Vitamin K antagonists

Clot removal

Fibrinolysis Plasmin Fibrin Fibrin Split Products (FSP)

Fibrinolysis Plasminogen tPA Plasmin Fibrin Fibrin Split Products (FSP)

Inhibitors of fibrinolysis Plasminogen activator inhibitors (PAIs) a2-antiplasmin (serpin)